stethoscope on table


Quality & Safety Update — January/February 2021


Jessica Stultz

Jessica Stultz

Director of Clinical Quality



Quality & Safety Update


  • Quality and Safety


quality and safety

The Quality & Safety Update provides health care professionals with up-to-date information on current quality improvement projects, resources and quality reporting. The newsletter also highlights announcements and upcoming events that could benefit your organization.

COVID-19 Update

For COVID-19 Updates, please visit the MHA COVID-19 web page.

To receive regular COVID-19 updates from MHA in your inbox, fill out the online form.

Maternal-Child Health

The Cuff Kit Project Comes To A Close

We officially have expended our funding for the Cuff Kit Project! Thank you to the 33 organizations that participated in this project to utilize telehealth technology to improve the health of women affected, or at risk, for hypertension and cardiovascular disease. Throughout the state, you have impacted the lives of 2,998 women by giving them a blood pressure cuff kit. We may never know the full bearing of each of these cuffs, but with projects like these, we know we are taking strides to Change Missouri’s Birth Story.

HHS Launches Initiative To Improve Maternal Health

The U.S. Department of Health and Human Services released its Action Plan and vision for improving maternal health. To achieve the vision in five years, the plan applies a “life course” approach, which is organized around four goals and sets the following three ambitious targets.

  • reduce the maternal mortality rate by 50%
  • reduce the low-risk cesarean delivery rate by 25%
  • Achieve blood pressure control in 80% of women of reproductive age with hypertension

The Action Plan is being released concurrently with the Surgeon General’s Call to Action to Improve Maternal Health. While HHS’ Action Plan summarizes work to ensure the U.S. is one of the safest countries in the world to give birth, the Surgeon General’s Call to Action outlines strategies and actions for a diverse set of external stakeholders to improve maternal health.

To achieve these goals, the Action Plan and Call to Action calls for work on the following.

  • improve prevention and treatment of cardiovascular disease
  • develop reporting quality measures related to maternal mortality and morbidity
  • improve quality of and access to postpartum care
  • promote the development of strong parent-child relationships

Additionally, the Action Plan notes there will be additional funding and expansion of AIM bundles on cardiovascular disease and maternal sepsis, and expansion of these bundles to outpatient and community settings.

For additional details, visit MHA’s Maternal-Child Health web page.

Opioid Use Disorder

MHA Publishes Statewide EPICC Status Report

MHA published the EPICC Statewide Status Report on behalf of all the local and state partners that work to connect patients from hospitals to evidence-based substance use treatment and grassroot recovery supports. Collectively, there are 118 unique Missouri agencies (80 active and 38 planning) that are participating in EPICC programming and/or infrastructure development. This broad base of EPICC stakeholders are supported by a technical assistance team comprised of an additional 10 agencies — with representation from local and state institutions.

Developing strong links between health care, first responder programs, education, transportation infrastructure, community services, mobile treatment centers, telemedicine support, the justice system and others is critical to providing a rich network of access points to local, regional and state opioid use disorder treatment and recovery support services.

This status report provides information on the background and purpose of EPICC, as well as its collaborative model, referral volume and program expansion. Also available is insight on programming challenges from the COVID-19 pandemic.

UMSL-MIMH Addiction Science Report

In September 2020, the Addition Science team at the University of Missouri—St. Louis, as part of the Missouri Institute for Mental Health, issued a report, “Drug-involved Deaths in St. Louis City and County in 2019: The Roles of Opioids, Stimulants, Race and Sex (and Age).” The report summarizes data based upon stimulant and opioid-related deaths, with the aim of the report to allow for broader information sharing regarding the difference in drug supplies, use patterns and availability of resources that may contribute to drug-involved deaths. Also available are key summary points and additional caveats to the information.

Additional resources are available in St. Louis for pregnant women that may increase their access to resources and substance use treatment facilities. Missouri also offers priority access to treatment programs and buprenorphine therapy for women who have substance use disorders during pregnancy. The WISH Clinic through SSM hospital system and the CARE Clinic at Barnes Jewish Hospital/Washington University are two programs in the St. Louis area specifically working with pregnant women with substance use disorders. Additionally, the Queen of Peace Center is a program for women with addiction and their children to assist with daycare, housing and more.

MHA, along with our partners at MIMH, realize the data in this report reflect more than a statistic. It reflects a human life lost. Gone too soon. We share this information in the hopes of helping and building resources, access to care and support to those who need our assistance.


MHA Recognizes Top Performing CAHs

While emergency care is important in all hospitals, the emergency department particularly is important in critical access hospitals where the distance to urban tertiary care centers makes the effective triage, stabilization and transfer of patients an area of focus. ED transfer communication measures allow CAHs to show how well they carry out their important stabilize-and-transfer role for rural residents. This measure is required of hospitals participating in the FLEX MBQIP program in Missouri and throughout the nation.

As of the third quarter of 2020, the following CAHs achieved 100% compliance in the ALL EDTC composite score, putting them in the top performers list of CAHs in Missouri and the nation.

  1. Cox Barton County Hospital
  2. Carroll County Memorial Hospital
  3. Cass Regional Medical Center
  4. Ellett Memorial Hospital
  5. Harrison County Community Hospital
  6. Lafayette Regional Health Center
  7. Mercy Hospital Lincoln
  8. Madison Medical Center
  9. Missouri Baptist Sullivan Hospital
  10. Mosaic Medical Center – Albany
  11. Perry County Memorial Hospital
  12. Mercy St. Francis Hospital


Aim for Excellence Award

MHA Awards

Each year, MHA presents health care organizations and leaders with prestigious awards recognizing outstanding personal achievement and honoring leadership in the delivery of health care. Due to the COVID-19 pandemic, the 2020 Aim for Excellence and Visionary Leadership Awards were suspended to allow hospital and health system staff time to devote addressing the needs of their hospitals and communities.

We are happy to announce we plan to resume the awards in 2021! Stay tuned – more information is forthcoming!

MHA Today

MoAHQ Update

Left to right: Dr. Steve Pautler, CEO of Ste. Genevieve County Memorial Hospital; DQP Award winner Laura Fowler; and Hirshell Parker, Director of Quality and Risk Management and MoAHQ President

Annually, the Missouri Association for Healthcare Quality sends a call for nominees for the Distinguished Quality Professional Award.

The award recognizes a professional who exhibits exceptional skills in health care quality in the areas of leadership, expertise, knowledge of quality principles and contributions to the health care quality profession, as well as being a role model for others in the field. In 2020, we congratulate Laura Fowler for being selected as the recipient of the Distinguished Quality Professional Award sponsored by MoAHQ. Her dedication to quality patient care is quite evident in the tremendous contribution she clearly made in her work.

The competition was fierce this year. Following are the tremendous nominees. We applaud all the hard work that transpired throughout the state, as evidenced by the outstanding accomplishments included in the nomination forms. Receiving a nomination for the DQP award is an honor, and we want to honor and recognize the continued dedication to improving health care quality in your community and regionally.

DQP Nominees

  • Anna Nattingly, Ste. Genevieve County Memorial Hospital
  • Brandy Beilsmith, SSM Health St. Louis
  • Corrine Fugitt, CoxHealth
  • Dan Sabourin, Landmark Hospital of Columbia
  • Julie Noah, Northeast Regional Medical Center
  • Pam Tarr, Ray County Community Hospital
  • Tonya Myers, Cass Regional Medical Center

Laura Fowler, DQP award winner, had the opportunity to present to the MoAHQ membership during the PMG programming at MHA’s annual convention. Also during the programming, poster presentations were presented by the authors who compiled their project story, submitted applications and were chosen to present during the MoAHQ programming. In addition, each poster’s author is invited to present didactic and answer questions during a full member MoAHQ virtual meeting in 2021.

Authors & Organization

Title of Study or Project

Boehm, H., Ramel, R. & Carlton, E. University of Kansas Medical Center

The Upside: Making a Difference for Patients with Complex Behavioral Health Needs
Carlson, A. L., Steele, A. S. & Drummond, S. L. Veterans Affair Medical Center Diagonal Interventions in Infection Prevention: Successful Infection Prevention and Nursing Collaboratives to Decrease Central Line-Associated Bloodstream Infections at a Veterans Affairs Medical Center
Friend, R., Williams, J., Cahow, N., Parsons, L., Schrag, J., Lucas, B. & Moncure, M. Truman Medical Center Responsive Individualized Support and Early Intervention (RISE) for PTSD Mitigation
Hong, E. Saint Louis University QI Initiatives to Reduce Maternal Mortality
McCurdy, T. Mercy Hospital St. Louis Behavioral Intervention Response Team (BIRT): Mercy’s Response to Keeping Our Coworkers Safe
Nicoletti, E. L. & Whealen, S. R. SSM Health Cardinal Glennon Children’s Hospital Our Journey to Zero Patient Harm: Taking Harm to Heart
Nicoletti, E. L. & Whealen, S. R. SSM Health Cardinal Glennon Children’s Hospital Leadership Safety Huddle: Creating Situational Awareness to Promote Error Prevention
Ramirez Henry, K. University of Missouri Kansas City A Postpartum Depression Screening Practice Change to Improve Pediatric Provider Knowledge and Identification of Postpartum Depression
Robbins, B., Hornick, J. & Harryman, S. University of Missouri Healthcare Early Detection of Deep Tissue Pressure Injury
Wade, S. & Osterbur, E. Saint Louis University Assessing the Non-medical Use of Prescription Stimulants Among College Students
Yelton, S. Saint Luke’s Hospital Using Performance Improvement Project Charters
COVID 19 Virus blue


The COVID-19 ECHO provides information and support for health care stakeholders. A multidisciplinary expert team shares developments, answers questions and discusses management of patient cases presented by participants.

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Managing Hospitals & Patients in a Pandemic ECHO

This is a COVID-19 ECHO with a more clinical and operational focus to assist hospitals with having the resources and knowledge base to care for COVID-19 patients at their facilities.

Mom holding her Baby

Mothers, Infants & NAS ECHO

The Mothers, Infants & NAS ECHO supports improvement of outcomes for the mother-infant dyad affected by SUD. Topics include evidence-based practices, collaboration, innovation and enhanced support systems.

Mother kissing her Newborn

Missouri Moms & Babies ECHO

The Missouri Moms & Babies ECHO addresses challenges in perinatal care and shares information about evidence-based practices, innovation, collaboration and community networks.

Upcoming Virtual Events

Feb. 23: MHA & DHSS: Missouri Neonatal Abstinence Syndrome Summit

The Missouri Neonatal Abstinence Syndrome Summit will bring together stakeholders who are working to discuss recent surveillance findings, continued trends and programming, and future opportunities for collaboration and evaluation. Learn more.

On-Demand Education

The MHA Health Institute offers cost-effective learning opportunities to both members and nonmembers to help them understand and address emerging issues, learn and share best practices, and comply with legal and regulatory requirements. Learn more.

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